Health Equity During COVID-19
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Division of General Internal Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, USA; 2Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06040-5 © Society of General Internal Medicine 2020
story of COVID-19 remains far from over, but we T healready know a principal lesson: disease prevention requires more than health systems. Although health systems are a critical component of public health, preventing death requires attention to the societal and economic conditions from which poor health emerge. People with chronic conditions are at increased risk of dying from COVID-19. This is, therefore, a disease that disproportionately kills people at the margins—individuals at heightened risk of morbidity and pre-mature death because of social circumstances and structural inequity and racism. That social and economic inequality is a major proliferative vector of COVID-19 should not come as a surprise. This is not the first time the social forces underlying health have contributed to a public health emergency. Our country is simultaneously battling another public health emergency also fundamentally fueled by social and economic determinants: the opioid overdose crisis. However, our response as a society to the opioid crisis has focused on prescribing as the etiology, largely ignoring the role of social and economic factors, such as the concentrated disadvantage, isolation, and trauma that have come to define the post-industrial landscape for many Americans. The emphasis on opioid supply has come with certain benefits. For example, it has promoted excellent treatments, including medications like buprenorphine and methadone. However, it has also justified mass incarceration for drug offenses and social safety net cuts—policies and practices that exacerbate “diseases of despair” and thus counteract the hard work carried out by people working on the frontlines of our health systems 1. In this moment, our focus is on curtailing the spread of the SARS-CoV-2 virus, widely considered the major vector of the COVID-19 pandemic. Health systems have done a remarkable job of mobilizing workforces to erect drive-through testing centers, pivoting to telehealth, and, ultimately, facilitating the Received April 20, 2020 Accepted July 3, 2020
“shelter in place” model. However, these interventions require a certain amount of privilege and, in so doing, exclude the millions of people in our country who stand to be the most severely affected by COVID-19 due to the way in which poverty and poor health operate synergistically with addiction, psychiatric disorders, disability, unstable housing, food insecurity, immigration status, and criminal justice involvement. For people on the margins, there is no car available for drivethrough testing, no home for sheltering in place, and no money to hoard toilet paper. For people living just inside the margins, there is no sick leave, quality child care, or health insurance or legal aid fo
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